19364 vs. S2068 for DIEP/SIEP Flaps

Dear John,

Q. There’s been ongoing confusion in our office regarding the proper coding of deep inferior epigastric perforator flap (DIEP) for breast reconstruction. Should we be using HCPCS Level II code S2068, or CPT® 19364? May we also code separately for partial rib resection (21600) when performed as part of the reconstruction?

A. The American Medical Association (AMA) addressed this issue in a “Bonus Feature: Special Q&A,” in the December 2011 CPT® Assistant:

Q. Should code 19364, Breast reconstruction with free flap, be used to report the performance of a deep inferior epigastric perforator flap (DIEP) for breast reconstruction?

A. Yes. Code 19364, Breast reconstruction with free flap, is the appropriate code to report free flap breast reconstruction, regardless of the specific free flap used. It may be a free transverse rectus abdominis myocutaneous (TRAM), a free DIEP, or a gluteal free flap. Code 19364 is not limited to a particular type of free flap, and it is the code to be used to report any type of free flap breast reconstruction.

Code 19364 includes harvesting of the flap, microvascular transfer (one artery and two veins), closure of the donor site, and transfer to the chest and inset, including the creation of the breast mound. Examples are a free transverse rectus abdominis myocutaneous (TRAM) flap, a free DIEP, or free gluteal flap. Microvascular transfer includes the use of the operating microscope. Code +69990 Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure) is
not reported in conjunction with code 19364.

The AMA also takes a position that a DIEP flap (and a superficial inferior epigastric artery (SIEA) flap), as described by 19364, includes partial rib resection. This was clarified in the March 2013 CPT® Assistant:

Q. May code 21600, Excision of rib, partial, be reported separately, in conjunction with breast reconstruction, when performed with a free flap?

A. No. CPT code 19364, Breast reconstruction with free flap, includes a partial rib resection and thus, code 21600 is not reported separately. Code 19364 includes the creation of a pocket, preparation of recipient vessels, harvest and transfer of flap to the recipient site, partial rib resection, microvascular anastomosis of one artery and two veins, closure of the donor site, and primary closure.

Based on the recent AMA clarifications, S2068 Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral is now redundant (although it remains “on the books” as an active HCPCS Level II code). You should report S2068 only if your payer/contract specifically calls for its use. Note that S codes, including S2068, are never payable by Medicare.

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Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

About Has 425 Posts

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

3 Responses to “19364 vs. S2068 for DIEP/SIEP Flaps”

  1. Jeanne Lee says:

    Thank you so much for this information, I have spent much time deciphering information hcpcs vs. cpt.

  2. Theresa says:

    ALL OF MY DOCTORS STATE THAT 19364 does not describe the procedure to the full extent that the DIEP AND SIEP FLAP ENTAIL. THEY STATE THIS SURGERY IS A VERY EXTENSIVE DETAILED PROCEDURE AND THEY STATE THIS PROCEDURE IS SUPERIOR TO THE FREE TRAM. THEY REFUSE TO BILL WITH THE 19364 CODE AS THEY SAY IF FULLY DOES NOT DESCRIBE OR COMPENSATE FOR THE PROCEDURE. THEY USE S2068 TO BILL THIS PROCEDURE AND MOST CARRIERS ACCEPT AND RECOGNIZE THIS CODE.
    SO IS THIS TRULY INCORRECT TO BILL THIS TYPE OF FLAP WITH THE S CODE

  3. amanda says:

    My doctor also bills with S2068, S2066 & S2067; for the same reason as the previous user commented. When billing some payers, S2068,66 & 67 are denied when billed with MOD-80, (doesn’t allow for an assistant. They will allow an assistant for 19364, so we use it in some cases.
    Wondering if anyone knows how to use 19364 and represent S2067 which is a ‘stacked flap’. The charge would normally be a higher rate for the multiple flaps harvested to create 1 breast. We do not want to change our fee schedule and bill different pricing for some these types of cases. ANY SUGGESTIONS??

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